CHOICE2 Trial Evaluates Intra-Arterial Alteplase Use After Thrombectomy

February 4, 2026—Delivering intra-arterial alteplase after successful mechanical thrombectomy improved functional recovery in patients with large vessel ischemic stroke, according to late-breaking results from the phase 3 CHOICE2 trial presented at the American Stroke Association’s International Stroke Conference 2026.

Mechanical thrombectomy is a guideline-recommended treatment for select patients with acute ischemic stroke due to large vessel occlusion, yet more than half of patients do not achieve full recovery despite angiographic reperfusion. Investigators in CHOICE2 evaluated whether local infusion of alteplase after clot removal could address persistent microvascular obstruction not detected on standard imaging.

The multicenter, randomized trial enrolled 433 adults with large-artery ischemic stroke who were treated at 14 stroke centers in Spain between December 2023 and August 2025. All patients achieved successful reperfusion with thrombectomy within 4.5 to 24 hours of symptom onset. Participants were randomized to thrombectomy alone (n = 219) or thrombectomy plus a 15-minute intra-arterial infusion of alteplase delivered to the affected artery (n = 214).

At 90 days, patients who received adjunctive alteplase were significantly more likely to achieve an excellent functional outcome, defined as little or no disability on the modified Rankin Scale (57.5% vs 42.5%), representing an absolute improvement of 15 percentage points. Imaging also showed a lower rate of inadequate microvascular perfusion in the combination therapy group compared with thrombectomy alone (28.6% vs 50.5%). Patients treated with intra-arterial alteplase additionally reported better mobility, self-care, and ability to perform usual activities, along with lower pain and anxiety scores on quality-of-life assessments.

Safety outcomes were comparable between groups. At 90 days, rates of symptomatic intracranial hemorrhage were low and not significantly different (1.4% with adjunctive alteplase vs 0.5% with thrombectomy alone), as were all-cause mortality rates (12.1% vs 6.4%).

“Mechanical thrombectomy alone is often not enough to fully restore blood flow to the injured brain, even when the blocked artery appears successfully reopened. Standard imaging can miss persistent blockages in the brain’s smallest blood vessels,” said study author Ángel Chamorro, MD, PhD, who is Professor of Neurology at the University of Barcelona. “Intra-arterial alteplase given after successful thrombectomy significantly increased the chances of an excellent recovery,”

CHOICE2 builds on earlier findings from the smaller CHOICE trial and aligns with results from recent studies using adjunctive thrombolytics after thrombectomy. Investigators emphasized that the current findings are practice-informing but require confirmation in additional trials before broader adoption.